Fill and Sign the Appellate Divisionpublished in the Law Journal on Form

JOHN LAWYER, ESQ. 12 Main Street Anywhere, USA Attorneys for Plaintiff _____________________________ JOHN DOE, Plaintiff, vs. JAMES SMITH, Defendant. _____________________________ SUPERIOR COURT OF NEW JERSEY [insert] COUNTY LAW DIVISION DOCKET NO.: CIVIL ACTION COMPLAINT, JURY DEMAND AND DESIGNATION OF TRIAL COUNSEL John Doe, residing at [insert address], by way of complaint against the Defendant, James Smith, residing at [insert address] 1. On [insert date], plaintiff was a guest of the defendant ฀s sister, Jane Smith, at their parent ฀s residence at [insert address]. 2. As the plaintiff was leaving the residence going down the front steps, he was caused to fall down the steps by the defendant. 3. The defendant was negligent and failed to act reasonably in walking down the steps with the plaintiff and causing the plaintiff to fall down the steps. WHEREFORE, plaintiff, John Doe, demands judgment against the defendant, James Smith, on the First Count of the Complaint, together with interest and costs of suit. Dated: ___________________________ JOHN LAWYER JURY DEMAND The Plaintiff, John Doe hereby demands trial by a jury on all triable issues of this Complaint. DESIGNATION OF TRIAL COUNSEL Pursuant to rule 4:25-4, John Lawyer, is hereby designated as trial counsel for Plaintiff, John Doe, in the above matter. CERTIFICATION OF NO OTHER ACTION Pursuant to rule 4:5-1, it is hereby stated that the matter in controversy is not the subject of any other action pending in any other court or of a pending arbitration proceeding to t he best of my knowledge or belief. Also, to the best of my belief, no other action or arbitration proceeding is contemplated. Further, other than the parties set forth in this pleadi ng, we know of no other parties that should be joined in the above action. In addition, we recognize t he continuing obligation of each party to file and serve on all parties and the court an amended certification if there is a change in the facts stated in this original certification. Dated: ________________________________ JOHN LAWYER